Implicit awareness in anosognosia: clinical observations, experimental evidence, and theoretical implications

Exploring the Cognitive Profiles of Haemodialysis Patients using Objective and Subjective Indicators: A Cross-sectional Observational Study

BACKGROUND

Cognitive impairment is common in haemodialysis patients and associated with adverse health outcomes. Previous work focused primarily on neuropsychological tests, the gold standard measure of cognition. However, these tests reflect performance under optimal conditions rather than performance in everyday life. This study aims to assess both objective and subjective cognition in haemodialysis patients.

METHODS

Adult haemodialysis patients completed measures of objective cognitive impairment (Montreal Cognitive Assessment), subjective cognitive complaints, mood and fatigue symptoms, and provided sociodemographic information. Clinical data such as comorbidity were extracted from patients' medical record.

RESULTS

A total of 268 haemodialysis patients (mean age = 59.87 years; 42.5% female) participated. Only 25.0% of the sample had normal cognition, while the rest had either objective cognitive impairments or clinically significant cognitive complaints, or both (both objective impairments and subjective complaints: 26.1%; objective impairments without complaint: 38.4%; significant complaints without objective impairments: 10.4%). Lower education was associated with the presence of objective cognitive impairments, whereas depression was associated with the presence of clinically significant cognitive complaints. Patients who exhibited both objective cognitive impairments and significant cognitive complaints were more likely to have diabetes and higher dialysis dose (Kt/V). Patients with objective cognitive impairments but no significant complaints were significantly older.

CONCLUSIONS

The cognitive burden of haemodialysis patients can be manifested as objective impairments and/or subjective complaints. When combined the two indicators may better represent the overall cognitive well-being in this population. There is a need to screen for cognitive difficulties and develop cognitive rehabilitative strategies in dialysis settings.

Resting-state networks and anosognosia in Alzheimer's disease

Background

Recent evidence suggests that anosognosia or unawareness of cognitive impairment in Alzheimer's Disease (AD) may be explained by a disconnection between brain regions involved in accessing and monitoring information regarding self and others. It has been demonstrated that AD patients with anosognosia have reduced connectivity within the default mode network (DMN) and that anosognosia in people with prodromal AD is positively associated with bilateral anterior cingulate cortex (ACC), suggesting a possible role of this region in mechanisms of awareness in the early phase of disease. We hypothesized that anosognosia in AD is associated with an imbalance between the activity of large-scale resting-state functional magnetic resonance imaging (fMRI) networks, in particular the DMN, the salience network (SN), and the frontoparietal network (FPN).

Methods

Sixty patients with MCI and AD dementia underwent fMRI and neuropsychological assessment including the Anosognosia Questionnaire Dementia (AQ-D), a measure of anosognosia based on a discrepancy score between patient's and carer's judgments. After having applied Independent Component Analysis (ICA) to resting fMRI data we performed: (i) correlations between the AQ-D score and functional connectivity in the DMN, SN, and FPN, and (ii) comparisons between aware and unaware patients of the DMN, SN, and FPN functional connectivity.

Results

We found that anosognosia was associated with (i) weak functional connectivity within the DMN, in posterior and middle cingulate cortex particularly, (ii) strong functional connectivity within the SN in ACC, and between the SN and basal ganglia, and (iii) a heterogenous effect concerning the functional connectivity of the FPN, with a weak connectivity between the FPN and PCC, and a strong connectivity between the FPN and ACC. The observed effects were controlled for differences in severity of cognitive impairment and age.

Conclusion

Anosognosia in the AD continuum is associated with a dysregulation of the functional connectivity of three large-scale networks, namely the DMN, SN, and FPN.

Exploring longitudinal changes in implicit awareness of dementia: An investigation of the emotional Stroop effect in healthy ageing and mild dementia

The aim of the study was to investigate responses to dementia-relevant words in healthy older people and to investigate changes in response over 20-months in people with early-stage dementia. An emotional Stroop task, using colour-naming dementia-relevant words, was used as an indicator of implicit awareness of dementia. Overall, 24 people with dementia and 24 healthy older people completed an emotional Stroop task (T1). People with dementia completed the same task again after 12 (T2) and 20 (T3) months. For people with dementia emotional Stroop performance was contrasted with ratings of explicit awareness based on a detailed interview at T1 and at T2. For healthy older people and people with dementia response times to dementia-relevant words were significantly longer than those for neutral words. The effect was absent for people with dementia at T3. This decline in the emotional Stroop effect was not associated with cognitive decline as measured by the MMSE. Ratings of explicit awareness showed no significant change over time. There was no association between explicit awareness and implicit awareness. Implicit awareness of the condition is evident in early-stage dementia and can be elicited even where there is reduced explicit awareness. The emotional Stroop effect for dementia-relevant words in people with dementia appears to decline over time, independently of changes in MMSE score, suggesting that implicit awareness fades as time progresses.

Neural correlates of impaired cognitive processes underlying self-unawareness in Alzheimer's disease

Self-unawareness concerning current symptoms remains a clinical challenge in Alzheimer's disease. Reduced self-awareness likely depends on complex biopsychosocial mechanisms that comprise multiple cognitive processes, regulated by personal goals and values. We specifically reviewed the cognitive processes impaired in unaware participants with AD by emphasizing the related impaired brain activity observed during task-based fMRI. Unawareness can be explained by a failure in functioning of or in connection between brain regions that intervene in access, retrieval and updating of (present or extended) self-information (posterior midline, medial temporal, inferior parietal cortices), or in its monitoring, evaluation, or control (medial and lateral prefrontal cortices). Although one must be cautious when relating function to brain regions, impaired processes were tentatively related to the Cognitive Awareness Model. Although brain function depends on neural networks, impaired brain activity during cognitive processes was discussed according to previous studies reporting correlations between brain regions and scores of anosognosia. The review provides a framework to help clinicians considering processes that can explain unawareness in dementia. In patients at early stages of AD, different levels of awareness of cognitive or social clinical changes might be described as impairment in the interaction between specific cognitive processes and contents.

Implicit Selective Attention: The Role of the Mesencephalic-basal Ganglia System

The ability of the brain to recognize and orient attention to relevant stimuli appearing in the visual field is highlighted by a tuning process, which involves modulating the early visual system by both cortical and subcortical brain areas. Selective attention is coordinated not only by the output of stimulus-based saliency maps but is also influenced by top-down cognitive factors, such as internal states, goals, or previous experiences. The basal ganglia system plays a key role in implicitly modulating the underlying mechanisms of selective attention, favouring the formation and maintenance of implicit sensory-motor memories that are capable of automatically modifying the output of priority maps in sensory-motor structures of the midbrain, such as the superior colliculus. The article presents an overview of the recent literature outlining the crucial contribution of several subcortical structures to the processing of different sources of salient stimuli. In detail, we will focus on how the mesencephalic- basal ganglia closed loops contribute to implicitly addressing and modulating selective attention to prioritized stimuli. We conclude by discussing implicit behavioural responses observed in clinical populations in which awareness is compromised at some level. Implicit (emergent) awareness in clinical conditions that can be accompanied by manifest anosognosic symptomatology (i.e., hemiplegia) or involving abnormal conscious processing of visual information (i.e., unilateral spatial neglect and blindsight) represents interesting neurocognitive "test cases" for inferences about mesencephalicbasal ganglia closed-loops involvement in the formation of implicit sensory-motor memories.

Anosognosia in moderate-to-severe traumatic brain injury: A review of prevalence, clinical correlates, and diversity considerations

METHOD

A comprehensive search of peer-reviewed articles was conducted from September to November 2020 using Google Scholar and PubMed databases. Key terms included "anosognosia," "self-awareness," "traumatic brain injury," and variants thereof. Our search was restricted to articles published in English within the last 25 years, although a few historical articles were included due to scientific merit. Articles were chosen based on methodological quality, inclusion of solely or predominantly msevTBI sample, and relevance to the current topic.

CONCLUSIONS

Anosognosia is a multifaceted and domain-specific construct that affects the majority of those with msevTBI. It is related to TBI severity, injuries in right-hemispheric and cortical midline regions, specific aspects of executive function, psychological function, and cultural factors. We offer pragmatic advice for clinicians working with this population and discuss implications for the field regarding "best practices" of anosognosia assessment and intervention.

Motor awareness: a model based on neurological syndromes

Motor awareness is a complex, multifaceted construct involving the awareness of both (i) one's motor state while executing a movement or remaining still and (ii) one's motor abilities. The analysis of neurological syndromes associated with motor disorders suggests the existence of various different components which are, however, integrated into a model of motor awareness. These components are: (i) motor intention, namely, a conscious desire to perform an action; (ii) motor monitoring and error recognition, that is, the capacity to check the execution of the action and identify motor errors; and (iii) a general awareness of one's own motor abilities and deficits, that is, the capacity to recognize the general state of one's motor abilities about the performance of specific actions and the potential consequences of motor impairment. Neuroanatomical correlates involving the parietal and insular cortices, the medial and lateral frontal regions, and subcortical structures (basal ganglia and limbic system) support this multi-component model. Specific damage (or disconnections) to these structures results in a number of different disorders in motor awareness, such as anosognosia for hemiplegia and apraxia, and a number of symptoms which are specific to motor intention disorders (e.g., the Anarchic Hand Syndrome and Tourette's Syndrome) or motor monitoring (e.g., Parkinson's and Huntington's diseases). All of these clinical conditions are discussed in the light of a motor awareness model.

Eliciting Implicit Awareness in Alzheimer’s Disease and Mild Cognitive Impairment: A Task-Based Functional MRI Study

Background

Recent models of anosognosia in dementia have suggested the existence of an implicit component of self-awareness about one’s cognitive impairment that may remain preserved and continue to regulate behavioral, affective, and cognitive responses even in people who do not show an explicit awareness of their difficulties. Behavioral studies have used different strategies to demonstrate implicit awareness in patients with anosognosia, but no neuroimaging studies have yet investigated its neural bases.

Methods

Patients with amnestic mild cognitive impairment and dementia due to Alzheimer’s disease underwent functional magnetic resonance imaging (fMRI) during the execution of a color-naming task in which they were presented with neutral, negative, and dementia-related words (Dementia-Related Emotional Stroop).

Results

Twenty-one patients were recruited: 12 were classified as aware and 9 as unaware according to anosognosia scales (based on clinical judgment and patient-caregiver discrepancy). Behavioral results showed that aware patients took the longest time to process dementia-related words, although differences between word types were not significant, limiting interpretation of behavioral results. Imaging results showed that patients with preserved explicit awareness had a small positive differential activation of the posterior cingulate cortex (PCC) for the dementia-related words condition compared to the negative words, suggesting attribution of emotional valence to both conditions. PCC differential activation was instead negative in unaware patients, i.e., lower for dementia-related words relative to negative-words. In addition, the more negative the differential activation, the lower was the Stroop effect measuring implicit awareness.

Conclusion

Posterior cingulate cortex preserved response to dementia-related stimuli may be a marker of preserved implicit self-awareness.

Changes in awareness of condition in people with mild-to-moderate dementia: Longitudinal findings from the IDEAL cohort

OBJECTIVES

Awareness of difficulties shown by people with dementia is known to vary, but few studies have explored changes in awareness over time. Investigating this could further the understanding of surrounding concepts and reasons for impaired awareness. Recognising emerging or diminishing awareness could facilitate discussions about diagnosis and appropriate post-diagnostic support.

METHODS

Using longitudinal data from the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort, awareness in community-dwelling people with mild-to-moderate dementia was assessed at three timepoints over 2 years. A validated checklist was used to evaluate awareness of difficulties associated with dementia. We examined changes in awareness for people with low awareness at baseline, and used case-matching to describe differences in characteristics between people who gained awareness, and those who continued with low awareness.

RESULTS

At baseline, 83 people from a sample of 917 showed low awareness. The majority of those remaining in the study at later timepoints had gained awareness, some as late as four or more years after diagnosis. Case-matched comparisons revealed few distinguishing characteristics: cases with stable low awareness had similar or better cognitive and functional ability than those who gained and retained awareness at 12 and 24 months, but may have had more co-morbidities.

CONCLUSIONS

Self-reported awareness of difficulties can change and may increase over time in people with mild-to-moderate dementia. There may be individual reasons for ongoing low awareness, not explained by cognitive or functional ability. This challenges the view that a single record of low awareness represents a fixed disease-related symptom, and highlights the complex, individual and dynamic nature of awareness.

Self-awareness in Dementia: a Taxonomy of Processes, Overview of Findings, and Integrative Framework

Purpose of Review

Self-awareness, the capacity of becoming the object of one’s own awareness, has been a frontier of knowledge, but only recently scientific approaches to the theme have advanced. Self-awareness has important clinical implications, and a finer understanding of this concept may improve the clinical management of people with dementia. The current article aims to explore self-awareness, from a neurobiological perspective, in dementia.

Recent Findings

A taxonomy of self-awareness processes is presented, discussing how these can be structured across different levels of cognitive complexity. Findings on self-awareness in dementia are reviewed, indicating the relative preservation of capacities such as body ownership and agency, despite impairments in higher-level cognitive processes, such as autobiographical memory and emotional regulation.

Summary

An integrative framework, based on predictive coding and compensatory abilities linked to the resilience of self-awareness in dementia, is discussed, highlighting possible avenues for future research into the topic.

An evolutionary view of self-awareness

The capacity to be self-aware is regarded as a fundamental difference between humans and other species. However, growing evidence challenges this notion, indicating that many animals show complex signs and behaviors that are consonant with self-awareness. In this review, we suggest that many animals are indeed self-aware, but that the complexity of this process differs among species. We discuss this topic by addressing several different questions regarding self-awareness: what is self-awareness, how has self-awareness been studied experimentally, which species may be self-aware, what are its potential adaptive advantages. We conclude by proposing alternative models for the emergence of self-awareness in relation to species evolutionary paths, indicating future research questions to advance this field further.

Mental and Physical Self-Awareness of Alzheimer Patients: Decreased Awareness of Amnesia and Increased Fear of Falling Compared to Views of Families: The Tajiri and Wakuya Projects

INTRODUCTION

The purpose of this study is to examine self-awareness of patients with Alzheimer disease (AD) regarding forgetfulness and physical status, with the goal of further psychological understanding of these patients.

METHODS

The 255 subjects included 33 healthy volunteers and 48 patients with mild cognitive impairment who were elderly community residents selected from the 2017 Wakuya Project and 174 consecutive outpatients with AD at the Tajiri Clinic. Test data were selected from a pooled database. Results from the Mini-Mental State Examination, Clinical Dementia Rating (CDR), Short Falls Efficacy Scale International (FES), and Everyday Memory Checklist (EMC) were used in the study. FES and EMC data were also obtained from family members for comparison.

RESULTS

EMC scores in the AD groups (mild to moderate and moderate to severe) were significantly higher (more complaining memory impairment) than those in the CDR 0 (healthy) group and significantly lower (less self-awareness for memory impairment) than the corresponding EMC scores of families of the subjects. In contrast, FES scores of the AD groups did not differ significantly from those of the CDR 0 group, and these scores were higher (more fear of falling) than those of family members. Additionally, family-FES scores of the AD groups were higher than those of the CDR 0 and 0.5 groups.

CONCLUSION

The results showed an evidence of the heterogeneity of awareness, an emotional response (concern or fear, FES), and a cognitive appraisal of function (EMC). These may be explained whereby awareness of/fear of falling increases with AD due to a preserved emotional awareness, whereas awareness of cognitive impairment is impaired due to memory deficits.

Measuring Awareness in People With Dementia: Results of a Systematic Scoping Review

BACKGROUND

Awareness of the diagnosis or related changes in functioning varies in people with dementia (PwD), with implications for the well-being of PwD and their carers. Measuring awareness in a clinical setting could facilitate tailored support and optimize involvement in personal health and care decisions. This scoping review aimed to identify validated methods of assessing awareness in dementia and appraise their clinical utility.

METHOD

A systematic search was conducted of English-language publications that measured awareness in PwD, in 6 electronic databases. Search terms included dement*, Alzheimer*, Pick disease, and awareness, unawareness, anosognosia, insight, denial, metacognit*, or discrepanc*.

RESULTS

We screened 30,634 articles, finding 345 articles that met our inclusion criteria. We identified 76 measures, most commonly using a discrepancy questionnaire comparing evaluations of function by PwD and an informant. There were 30 awareness measures developed and validated for use in dementia populations but few designed for general clinical use.

CONCLUSIONS

Although we found a range of clinical indications for measuring awareness, there were few studies investigating clinical applications and few tools designed for clinical purposes. Further investigation and development of a person-centered tool could facilitate health and care choices in mild-to-moderate dementia.

Updating beliefs beyond the here-and-now: the counter-factual self in anosognosia for hemiplegia

The syndrome of anosognosia for hemiplegia, or the lack of awareness for one’s paralysis following right hemisphere stroke, can provide unique insights into the neurocognitive mechanisms of self-awareness. Yet it remains unclear whether anosognosia for hemiplegia is a modality-specific deficit of sensorimotor monitoring, or whether domain-general processes of attention and belief-updating converge to cause anosognosia for hemiplegia. Using a Bayesian learning framework, we formalized and empirically investigated the hypothesis that failures to update anosognosic beliefs can be explained by abnormalities in the relative uncertainty (i.e. precision) ascribed to prior beliefs versus sensory information in different contexts. We designed a new motor belief-updating task that manipulated both the temporal (prospective and retrospective) and spatial (hemispace most affected by inattention and hemispace less affected by inattention) conditions in which beliefs had to be updated, and we validated its sensitivity to anosognosia for hemiplegia in 26 patients with right hemisphere stroke. We then computed and empirically tested two different Bayesian predictors of prospective beliefs using two proxies for precision in anosognosia for hemiplegia patients: (i) standardized, neuropsychological measures of objective attention abilities, i.e. visuospatial neglect scores and (ii) subjective uncertainty reports, i.e. confidence ratings. Our results suggest that while neglect does not affect local, sensorimotor error monitoring, it does seem to affect the degree to which observed errors are used to update more general, prospective beliefs about counterfactual motor abilities in anosognosia for hemiplegia. Difficulties in such ‘counterfactual’ belief-updating were associated with disruptions in tracts of the ventral attentional network (i.e. superior longitudinal fasciculus connecting the temporo-parietal junction and ventral frontal cortex) and associated lesions to the insula, inferior parietal cortex and superior temporal regions. These results suggest that self-awareness extends beyond local, retrospective monitoring, requiring also salience-based, convergence of beliefs about the self that go beyond the ‘here-and-now’ of sensorimotor experience.

Conceptualization of self-awareness in adults with acquired brain injury: A qualitative systematic review

Self-awareness is an important consideration in cognitive rehabilitation for clinicians working with individuals following acquired brain injury (ABI), with impaired self-awareness linked to poor outcomes. To appropriately target assessment and intervention for self-awareness, its theoretical foundation and definition must be considered. The aim was to identify the definitions, theoretical models and conceptual frameworks of self-awareness in adults with ABI, and how self-awareness is conceptualized within those models. A qualitative systematic review was completed using search terms related to descriptions of models/frameworks, ABI and self-awareness. Data were analysed by narrative synthesis. Thirty-five papers were included in the review. Within these, 13 models, 12 conceptual frameworks and 2 theories were described. The main themes and subthemes conceptualized in the synthesis were: Clinical presentation of self-awareness (classifications and dimensions of self-awareness), development of self-awareness (knowledge, feedback mechanisms, temporal aspects, self-evaluation, enablers, barriers), understanding (dys)function (cognitive processing mechanisms, neurological foundations, causal factors), and practice guidance (assessment and intervention). This review identified an extensive theoretical basis to support conceptualization of self-awareness following ABI, underpinned by a distinction between intellectual awareness, on-line awareness, and psychological denial. Clinical application of an evaluation process that includes these elements would be beneficial to inform the rehabilitation process.

The Seven Selves of Dementia

The self is a complex and multifaceted phenomenon, encompassing a variety of cognitive processes and psychosocial influences. Considering this, there is a multiplicity of "selves," the current review suggesting that seven fundamental self-processes can be identified that further our understanding of the experience of dementia. These include (1) an embodied self, manifest as corporeal awareness; (2) an agentic self, related to being an agent and influencing life circumstances; (3) an implicit self, linked to non-conscious self-processing; (4) a critical self, which defines the core of self-identity; (5) a surrogate self, based on third-person perspective information; (6) an extended self, including external objects or existences that are incorporated into the self; and, finally, (7) an emergent self, a property of the self-processes that give rise to the sense of a unified self. These are discussed in relation to self-awareness and their use in making sense of the experience of dementia.

Metacognition of emotion recognition across neurodegenerative diseases

Metacognition (monitoring) of emotion recognition is fundamental for social interactions. Correct recognition of and confidence in the emotional meaning inferred from others' faces are fundamental for guiding and adjusting interpersonal behavior. Yet, although emotion recognition impairments are well documented across neurodegenerative diseases, the role of metacognition in this domain remains poorly understood. Here, we evaluate multimodal neurocognitive markers of metacognition in 83 subjects, encompassing patients with behavioral variant frontotemporal dementia [bvFTD, n = 18], Alzheimer's disease [AD, n = 27], and demographically-matched controls (n = 38). Participants performed a classical facial emotion recognition task and, after each trial, they rated their confidence in their performance. We examined two measures of metacognition: (i) calibration: how well confidence tracks accuracy; and (ii) a metacognitive index (MI) capturing the magnitude of the difference between confidence and accuracy. Then, whole-brain grey matter volume and fMRI-derived resting-state functional connectivity were analyzed to track associations with metacognition. Results showed that metacognition deficits were linked to basic emotion recognition. Metacognition of negative emotions was compromised in patients, especially disgust in bvFTD as well as sadness in AD. Metacognition impairments were associated with reduced volume of fronto-temporo-insular and subcortical areas in bvFTD and fronto-parietal regions in AD. Metacognition deficits were associated with disconnection of large-scale fronto-posterior networks for both groups. This study reveals a link between emotion recognition and metacognition in neurodegenerative diseases. The characterization of metacognitive impairments in bvFTD and AD would be relevant for understanding patients' daily life changes in social behavior.

Impaired explicit self-awareness but preserved behavioral regulation in patients with Alzheimer disease

OBJECTIVES

Impairments of metacognitive skills represent a critical symptom in Alzheimer Disease (AD) because it frequently results in a lack of self-awareness. However, recent findings suggest that, despite an inability to explicitly estimate their own cognitive functioning, patients might demonstrate some implicit recognition of difficulties. In this study, we tested whether a behavioral dissociation between explicit and implicit measures of metacognition can be found in both healthy older controls (n = 20) and AD patients (n = 20).

METHODS

Our two groups of participants (AD vs. Controls) were asked to complete a forced-choice perceptual identification test and to explicitly rate their confidence in each decision (i.e. explicit measure of metacognition). Moreover, they also had the opportunity to ask for a cue to help them decide if their response was correct (i.e. implicit measure of metacognition).

RESULTS

Data revealed that all participants asked for a cue more often after an incorrect response than after a correct response in the forced-choice identification test, indicating a good ability to implicitly introspect on the results of their cognitive operations. On the contrary, only healthy participants displayed metacognitive sensitivity when making explicit confidence judgments.

CONCLUSION

Our findings suggest that implicit metacognition may be less affected than explicit metacognition in Alzheimer's disease.

Understanding Alzheimer's disease as a disorder of consciousness

People with Alzheimer's disease (AD) demonstrate a range of alterations in consciousness. Changes in awareness of cognitive deficit, self-awareness, and introspection are seen early in AD, and dysfunction of awareness and arousal progresses with increasing disease severity. However, heterogeneity of deficits between individuals and a lack of empirical studies in people with severe dementia highlight the importance of identifying and applying biomarkers of awareness in AD. Impairments of awareness in AD are associated with neuropathology in regions that overlap with proposed neural correlates of consciousness. Recent developments in consciousness science provide theoretical frameworks and experimental approaches to help further understand the conscious experience of people with AD. Recognition of AD as a disorder of consciousness is overdue, and important to both understand the lived experience of people with AD and to improve care.

Anosognosia for theory of mind deficits: A single case study and a review of the literature

Being aware of one's own ability to interact socially is crucial to everyday life. After a brain injury, patients may lose their capacity to understand others' intentions and beliefs, that is, the Theory of Mind (ToM). To date, the debate on the association between ToM and other cognitive deficits (in particular executive functions and behavioural disorders) remains open and data regarding awareness of ToM deficits are meagre. By means of an ad-hoc neuropsychological battery of tests, we report on a patient who suffers from ToM deficits and is not aware of these disorders, although aware of his other symptoms. The study is accompanied by a review of the literature (PRISMA guidelines) demonstrating that ToM deficits are independent of executive functions. Furthermore, an advanced lesion analysis including tractography was executed. The results indicate that: i) ToM deficits can be specific and independent of other cognitive symptoms; ii) unawareness may be specific for ToM impairment and not involve other disorders and iii) the medial structures of the limbic, monitoring and attentional systems may be involved in anosognosia for ToM impairment.

Mnemonic monitoring in anosognosia for memory loss

OBJECTIVE

Anosognosia, or unawareness, for memory loss has been proposed to underlie cognitive functions such as memory and executive function. However, there is an inconsistent association between these constructs. Recent studies have shown that compromise ongoing self-monitoring of one's memory associates with anosognosia for memory loss. Yet to date it is unclear which memory monitoring mechanisms are impaired in these patients. In this study, we examined the extent to which temporal monitoring or orbitofrontal reality filtering (e.g., ability to monitor the temporal relevance of a memory) and source monitoring (e.g., the ability to distinguish which memories stem from internal as opposed to external sources) are associated with awareness of memory deficits.

METHOD

A total of 35 patients (M = 69 years; M = 14 years of education) with memory difficulties following a stroke were recruited from outpatient clinics. Patients were assessed with measures of self-awareness of memory difficulties, cognitive abilities and 2 experimental paradigms assessing source and temporal monitoring.

RESULTS AND CONCLUSION

Results showed that patients unaware of their memory difficulties were more likely to externalize the source of their memories. Specifically, those unaware of their deficits were more likely to assign an external source to memories that were internally produced (e.g., imagined). No differences were observed in relation to temporal monitoring between patients aware and unaware of their deficits. This study informs current theoretical models of self-awareness of memory loss. Future studies should attempt to replicate these findings and explore different memory monitoring mechanisms in relation to anosognosia for memory loss. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Anosognosia for limb and bucco-facial apraxia as inferred from the recognition of gestural errors

Anosognosia is a multifaceted syndrome characterized by a lack of awareness of motor, cognitive, or emotional deficits. While most studies have focused on basic motor disorders such as hemiplegia, only recently, the issue of whether anosognosia also concerns higher-order motor disorders like apraxia has been addressed. Here, we explore the existence of a specific form of anosognosia for apraxia in forty patients with uni-hemispheric vascular lesions. The patients were requested to imitate actions involving upper limb or bucco-facial body parts and then judge their performance. Successively, they were also asked to observe video recordings of the same actions performed by themselves or by other patients and judge the accuracy of the displayed actions. The comparison of participants versus examiner judgement and between error recognition of others' versus self's actions was considered as an index of awareness deficit for the online and offline conditions, respectively. Evidence was found that awareness deficits occurred both immediately after action execution (online anosognosia) and in the video recording task (offline anosognosia). Moreover, bucco-facial and limb apraxic patients were specifically unaware of their errors in bucco-facial and limb actions, respectively, indicating for the first time a topographical organization of the syndrome. Our approach allowed us to distinguish awareness deficits from more general disorders in error recognition; indeed, anosognosic patients were able to identify errors when the same action was executed by another patient but not when the video showed their own actions. Finally, we provide evidence that anosognosia for apraxia might be associated with frontal cortical and subcortical networks.

False Memory in Alzheimer's Disease

Patients with Alzheimer's Disease (AD) not only are suffering from amnesia but also are prone to memory distortions, such as experiencing detailed and vivid recollections of episodic events that have never been encountered (i.e., false memories). To describe and explain these distortions, we offer a review to synthesize current knowledge on false memory in AD into a framework allowing for better understanding of the taxonomy and phenomenology of false memories and of the cognitive mechanisms that may underlie false memory formation in AD. According to this review, certain phenomenological characteristics of memories (e.g., high emotional load, high vividness, or high familiarity) result in misattributions in AD. More specifically, this review proposes that generalized decline in cognitive control and inhibition in AD may result in difficulties in suppressing irrelevant information during memory monitoring, especially when irrelevant (i.e., false) information is characterized by high emotion, vividness, or familiarity. This review also proposes that binding deficits in AD decrease the ability to retrieve relevant contextual details, leading to source monitoring errors and false memories. In short, this review depicts how phenomenological characteristics of memories and failures of monitoring during retrieval contribute to the occurrence of false memory in AD.

Explicit and implicit monitoring in neurodegeneration and stroke

Monitoring is a complex multidimensional neurocognitive phenomenon. Patients with fronto-insular stroke (FIS), behavioural variant frontotemporal dementia (bvFTD) and Alzheimer’s disease (AD) show a lack of self-awareness, insight, and self-monitoring, which translate into anosognosia and daily behavioural impairments. Notably, they also present damage in key monitoring areas. While neuroscientific research on this domain has accrued in recent years, no previous study has compared monitoring performance across these brain diseases and none has applied a multiple lesion model approach combined with neuroimaging analysis. Here, we evaluated explicit and implicit monitoring in patients with focal stoke (FIS) and two types of dementia (bvFTD and AD) presenting damage in key monitoring areas. Participants performed a visual perception task and provided two types of report: confidence (explicit judgment of trust about their performance) and wagering (implicit reports which consisted in betting on their accuracy in the perceptual task). Then, damaged areas were analyzed via structural MRI to identify associations with potential behavioral deficits. In AD, inadequate confidence judgments were accompanied by poor wagering performance, demonstrating explicit and implicit monitoring impairments. By contrast, disorders of implicit monitoring in FIS and bvFTD patients occurred in the context of accurate confidence reports, suggesting a reduced ability to turn self-knowledge into appropriate wagering conducts. MRI analysis showed that ventromedial compromise was related to overconfidence, whereas fronto-temporo-insular damage was associated with excessive wagering. Therefore, joint assessment of explicit and implicit monitoring could favor a better differentiation of neurological profiles (frontal damage vs AD) and eventually contribute to delineating clinical interventions.

Color Choice Preference in Cognitively Impaired Patients: A Look Inside Alzheimer's Disease Through the Use of Lüscher Color Diagnostic

Objective

To study the emotional state of cognitively impaired patients through the color choice preference in a group of Alzheimer's disease (AD) patients and compare it with a group of Mild Cognitive Impairment (MCI) patients and a matched control group.

Methods

A total of 71 AD, 50 MCI and 68 controls were consecutively evaluated. All patients and controls underwent the Mini Mental State Evaluation (MMSE) and the Lüscher color test.

Results

Cognitively impaired patients mainly chose auxiliary colors, in particular violet and brown, and rejected black and gray. AD patients predominantly chose forms corresponding to auxiliary colors. The auxiliary color choice negatively correlated with the MMSE score. MCI patients and controls had a higher presence of anxiety on gray table and controls had higher frustration and ambivalence, i.e., psychic complexity, on basic color tables.Data globally suggest that AD patients live with a feeling of personal change due to instability and emotional insecurity, experiencing physical discomfort and a bodily need of being welcomed in a favorable environment. They aspire to a sensitive understanding by someone with whom they can be identified. Differently, MCI patients have less of these needs; however, they feel more anxious.

Conclusion

The comprehension of the inner emotional state of cognitively impaired patients allows us to better communicate with them and effectively approach their behavioral disorders. Like other projective techniques, such as the tree-drawing test and the human figure-drawing test, Lüscher color test is proposed as a simple and unconventional approach to understand the emotional life of AD patients. The awareness of clinicians about the existential fragility and insecurity of such type of patients allows us not only to better manage their behavioral disturbances but also to improve their quality of life and that of their caregivers.

Anosognosia for hemiplegia as a tripartite disconnection syndrome

The syndrome of Anosognosia for Hemiplegia (AHP) can provide unique insights into the neurocognitive processes of motor awareness. Yet, prior studies have only explored predominately discreet lesions. Using advanced structural neuroimaging methods in 174 patients with a right-hemisphere stroke, we were able to identify three neural systems that contribute to AHP, when disconnected or directly damaged: the (i) premotor loop (ii) limbic system, and (iii) ventral attentional network. Our results suggest that human motor awareness is contingent on the joint contribution of these three systems.

Measuring awareness in people with dementia: protocol for a scoping review

BACKGROUND

People with dementia (PwD) vary in the degree of awareness they show about their situation, both generally concerning the diagnosis and more specifically around certain aspects or objects of awareness such as awareness of memory impairment, altered daily activities or social functioning. The extent of awareness or lack of awareness has consequences for well-being of PwD and carers, impacting on rates of hospital admission, institutionalization, mood, adjustment to diagnosis, outcomes from intervention and carer burden. An accurate estimation of a person's awareness could therefore be useful in a clinical setting to support PwD and their carers in making appropriate choices for health and care decisions, and could facilitate safe management by health care professionals, e.g. in an acute care setting. There is a range of different approaches to measuring awareness reported in the dementia research literature, with varying estimates of the frequency of lack of awareness, reflecting different methodologies and populations. The majority of the methods have been developed for research purposes and may not be suitable for clinical use. There are no recent scoping or systematic reviews of the available methods.

METHOD

We will conduct a scoping review of published studies that have assessed awareness in people with dementia of all types, and all degrees of severity. The systematic search will include the electronic databases PubMed, Embase, PsycInfo, CINAHL, Web of Science and Cochrane Library, using search terms for dementia ("dement*" or "Alzheimer*" or "Pick's disease") and "awareness", "unawareness", "anosognosia", "insight", "denial", "metacognit*" or "discrepanc*" identified from pilot searches. Findings will be mapped and described according to the method used, the setting and diagnosis and the object of awareness studied if specified. Validated measures will be identified.

DISCUSSION

This scoping review will provide an overview of the methods used to measure awareness in people with dementia, allowing comparison of the methods along with identification of validated measures. The methods or components will be appraised for potential clinical use, and gaps in research will be highlighted.

The recall of dementia-related and neutral words by people with dementia: The ironic process of thought suppression

OBJECTIVE

Thought suppression may not work effectively when people have a cognitive impairment. This study tests whether participants with dementia showed lessened or enhanced recall and recognition of dementia-related words compared with a control population.

METHODS

Fifty participants living with dementia with mild levels of cognitive impairment and a control group of 52 participants without a diagnosis of dementia took part. A list of 12 words, composed of six dementia-related and six neutral words matched for frequency and length, was read out on four occasions, with the word order being varied for each presentation. Recognition was also assessed.

RESULTS

There was an interaction between word-type and participant group at both recall and recognition. While control participants recalled more neutral than dementia-related words, there was no difference for dementia participants. However, dementia participants recognised a significantly higher proportion of the dementia-related words, while there was no difference in word-type recognition for control participants.

CONCLUSIONS

This study adapts a social psychological paradigm to explore whether an important psychological mechanism for reducing distress can be affected by cognitive impairment. Our findings suggest that for people living with dementia, thought suppression may be either ineffective in reducing conscious awareness of distal threats or operate in an ironic fashion. While threatening proximal material may be repressed from awareness, distal threats may return into implicit awareness. This casts new light on research and has clinical implications.

Autobiographical recall as a tool to enhance the sense of self in Alzheimer's disease

We investigated whether autobiographical retrieval would improve the sense of self in Alzheimer's disease (AD). Participants with AD and controls were asked to produce statements describing their self, i.e., statements to the question "Who am I?", after two conditions: after autobiographical retrieval and after a control verbal fluency task. The production of "Who am I?" statements was analyzed regarding three self-dimensions (i.e., physical self, social self, and psychological self). Results revealed better production of descriptions related to physical self, social self, and psychological self after autobiographical retrieval than after the control condition in AD patients and control participants. At a clinical level, encouraging patients to retrieve autobiographical memories may be used as a tool to activate the sense of self in AD. At a theoretical level, they are concordant with a model suggesting a bidirectional relationship between autobiographical memory and the self in AD.

Metacognition and self-awareness in Multiple Sclerosis

Although a large range of literature on awareness and metacognition focuses on different neurological populations, little attention has been paid to Multiple Sclerosis (MS). This paper gathers literatures related to studies of anosognosia and the theoretical construct of metacognition which both offer a means to operationalize and measure awareness in MS. We focused on both a clinical concern, regarding the relationship between subjective and objective evolution of cognitive performance, and the theoretical issue of metacognitive processes implicated in disease awareness. We identified 26 papers with findings related to awareness of cognitive impairment in MS using questionnaire-based or performance-based methods. We found support for the idea that the relationship between subjective evaluation and neuropsychological evaluation depends on disease duration and is strongly modulated by other variables, such as mood state. We propose that the metacognitive deficit for memory tasks in this population arises from memory impairment. Finally, we discuss methodological issues, variability in MS patients, and the domain specificity of metacognitive impairment.

Selective forgetting of self-threatening statements: Mnemic neglect for dementia information in people with mild dementia

OBJECTIVE

We tested whether people with dementia manifest selective forgetting for self-threatening information, the mnemic neglect effect (MNE). This selective forgetting is observed among healthy adults in the recall, but not the recognition, of self-threatening feedback.

METHODS

Sixty-four statements about dementia were rated for their level of negativity by 280 staff and students at University of the West of England. The 12 statements rated as most negative and the 12 statements rated as least negative were then read to 62 people with dementia. Participants were randomized to 1 of 2 conditions with the statements referring either to self or to another person. High-negativity and self-referent statements had strong threat potential. Participants recalled the statements and then completed a recognition task, which consisted of the 24 previously read statements and 24 new statements.

RESULTS

Participants manifested the MNE: They recalled fewer high-negativity (compared with low-negativity) statements, but only when these referred to the self rather than another person. This pattern occurred independently of levels of depression or anxiety. Participants also made more self-protective intrusion errors when the statements referred to the self than another person. Participants did not differ in their recognition of statements.

CONCLUSION

The MNE occurs among people with dementia. The selective forgetting of highly negative, self-referent statements serves to protect the self against the threat that dementia represents. Given the similarities between the MNE and the clinical phenomenon of repression, the findings may mark psychological processes that are implicated in the acceptance (or lack thereof) of a dementia diagnosis.

The impact of dementia, depression and awareness on activities of daily living in a sample from a middle-income country

OBJECTIVE

Previous studies have indicated that dementia and depression have a considerable impact on the functional capacity of older adults, also influencing awareness about ability. The purpose of the current study was to investigate the impact of dementia, depression and awareness on activities of daily living (ADL) in a sample from a middle-income country.

METHODS

The current study explored impairments in basic, instrumental and advanced ADL using a factorial design comparing four groups: people with dementia and depression, people with dementia without depression, older adults with depression but no dementia and healthy older adults. For each type of ADL, self-report and informant report was contrasted in order to investigate the issue of lack of awareness in relation to ADL.

RESULTS

Results indicate that dementia is associated with impairments in all types of ADL. Advanced ADL were also reduced in depressed participants. In addition, in the case of instrumental and basic ADL, informant report indicated less preserved abilities than participant self-report, particularly in people with dementia.

CONCLUSIONS

The findings highlight the importance of developing interventions and compensatory strategies to prevent loss of ADL in dementia, also suggesting that early intervention in older adults with depression should focus on advanced ADL to prevent social isolation and withdrawal. Finally, the findings indicate that self-information about ADL may be compromised in dementia, so clinicians exploring disability should consider fully different aspects of ADL in this group. Copyright © 2017 John Wiley & Sons, Ltd.

Repressive Coping Does Not Contribute to Anosognosia in First-Diagnosis Patients With Alzheimer Disease

Anosognosia is common in patients with Alzheimer disease (AD) even in early stages. Although neural correlates and the impact of cognitive dysfunctions have been described, possible psychodynamic processes such as a repressive coping style as described in other illnesses, have not been examined. Our study aimed to examine possible psychological influence factors on illness perception embracing a repressive coping style and cognitive functions in AD patients in the diagnostic process. Fifty-four subjects with mild AD diagnosed in our memory clinic were enrolled. Anosognosia was evaluated using a patient-caregiver discrepancy rating. All patients underwent comprehensive neuropsychological testing. In addition, characteristics of a repressive coping style were assessed. In total, 79.6% of our patients showed a lack of awareness at least to some degree. 33.3% of the patients were classified as repressors. Repressors and nonrepressors did not differ in cognition, or the unawareness score. Multivariate regression analysis showed that repressive coping style did not significantly contribute to anosognosia, but that verbal memory and naming ability had a strong influence. Although our data indicate that a high proportion of patients with mild AD show characteristics of repressive coping, this possible defense mechanism had no influence on the awareness of illness-related deficits measured by caregiver patient discrepancy.

Cross domain self-monitoring in anosognosia for memory loss in Alzheimer's disease

Anosognosia for memory loss is a common feature of Alzheimer's disease (AD). Recent theories have proposed that anosognosia, a disruption in awareness at a global level, may reflect specific deficits in self-monitoring, or local awareness. Though anosognosia for memory loss has been shown to relate to memory self-monitoring, it is not clear if it relates to self-monitoring deficits in other domains (i.e., motor). The current study examined this question by analyzing the relationship between anosognosia for memory loss, memory monitoring, and motor monitoring in 35 individuals with mild to moderate AD. Anosognosia was assessed via clinical interview before participants completed a metamemory task to measure memory monitoring, and a computerized agency task to measure motor monitoring. Cognitive and psychological measures included memory, executive functions, and mood. Memory monitoring was associated with motor monitoring; however, anosognosia was associated only with memory monitoring, and not motor monitoring. Cognition and mood related differently to each measure of self-awareness. Results are interpreted within a hierarchical model of awareness in which local self-monitoring processes are associated across domain, but appear to only contribute to a global level awareness in a domain-specific fashion.

Unawareness for Motor Impairment and Distorted Perception of Task Difficulty

OBJECTIVES

Anosognosia for motor impairment is a complex syndrome that can manifest itself under different forms, guiding patients' behavior and task decisions. However, current diagnostic tools tend to evaluate only more explicit aspects of anosognosia (asking the patients about their motor abilities) and fail to address more subtle features of awareness. We have developed a new assessment measure, the ECT (Errand Choice Test), where patients are asked to judge task difficulty rather than estimate their own impairment.

METHODS

We assessed awareness in a group of 73 unilateral left- and right-brain damaged (30 LBD and 43 RBD, respectively) patients by means of the VATAm, which explicitly requires them to evaluate their own motor abilities, and the ECT. A control group of 65 healthy volunteers was asked to perform the ECT under two conditions: Current condition (i.e., using both hands) and Simulated conditions (i.e., simulating hemiplegia).

RESULTS

A total of 27% of the patients showed different performance on the VATAm and ECT, 21% of the patients showing lack of awareness only on VATAm and 6% only on ECT. Moreover, despite the ECT identified a higher frequency of anosognosia after RBD (33.3%) than LBD (27.6%), this hemispheric asymmetry was not significant. Remarkably, anosognosic patients performed very similarly to controls in the "current condition", suggesting that anosognosic patients' ability to perceive the complexity of each task per se is not altered.

CONCLUSION

Different methods may be able to tackle different aspects of awareness and the ECT proved to be able to detect less evident forms of awareness. (JINS, 2018, 24, 45-56).

Anosognosia, denial of illness and the right hemisphere dominance for emotions: Some historical and clinical notes

Poor disease awareness ('anosognosia') is often observed in patients with various disabilities caused by brain damage. The lack of disease awareness can be due to the disruption of specific cognitive mechanisms and the development of psychodynamic mechanisms of denial. The aim of this paper is to review how these phenomena were discovered and evolved over time and to consider the relationships between them and the right hemisphere dominance for emotions. It is not clear whether the term 'anosognosia' refers to a basic mechanism that can explain similar awareness defects in different behavioural domains or whether it must be viewed as a multifaceted phenomenon in which both the disruption of cognitive or sensorimotor mechanisms and the emergence of motivational factors can play different roles in various forms of disease unawareness and in different kinds of 'anosognosic' patients.

Anosognosia for Memory Impairment in Addiction: Insights from Neuroimaging and Neuropsychological Assessment of Metamemory

In addiction, notably Alcohol Use Disorder (AUD), patients often have a tendency to fail to acknowledge the reality of the disease and to minimize the physical, psychological, and social difficulties attendant to chronic alcohol consumption. This lack of awareness can reduce the chances of initiating and maintaining sobriety. Presented here is a model focusing on compromised awareness in individuals with AUD of mild to moderate cognitive deficits, in particular, for episodic memory impairment-the ability to learn new information, such as recent personal experiences. Early in abstinence, alcoholics can be unaware of their memory deficits and overestimate their mnemonic capacities, which can be investigated with metamemory paradigms. Relevant neuropsychological and neuroimaging results considered suggest that the alcoholics' impairment of awareness of their attenuated memory function can be a clinical manifestation explained mechanistically by neurobiological factors, including compromise of brain systems that result in a mild form of mnemonic anosognosia. Specifically, unawareness of memory impairment in AUD may result from a lack of personal knowledge updating attributable to damage in brain regions or connections supporting conscious recollection in episodic memory. Likely candidates are posterior parietal and medial frontal regions known to be integral part of the Default Mode Network (DMN) and the insula leading to an impaired switching mechanism between the DMN and the Central-Executive Control (i.e., Lateral Prefronto-Parietal) Network. The cognitive concepts and neural substrates noted for addictive disorders may also be relevant for problems in self-identification of functional impairment resulting from injury following war-related blast, sport-related concussion, and insidiously occurring dementia.

Implicit and explicit self-related processing in relation to insight in patients with schizophrenia

INTRODUCTION

Self-related processing (SRP) has been associated with clinical and cognitive insight. We investigated the relationship between implicit SRP (ISRP) and explicit SRP (ESRP) and insight. We first hypothesised that impaired insight is associated with the extent to which implicit feedback is incorporated in the self-image and subsequently influences behaviour. Second, we hypothesised that impaired insight is related to the way patients handle explicit feedback and use it to guide subsequent behaviour, therefore we expected to find a positive relationship between level of insight and the explicit self-related processing task.

METHODS

Thirty-four schizophrenia patients and 23 healthy controls participated in the study. Patients were assessed with the Schedule for the Assessment of Insight-Expanded and the Beck Cognitive Insight Scale. ISRP was measured using a working memory two-back priming task. ESRP was measured with an adapted version of the Wisconsin Card Sorting Task where patients received explicit feedback on their performance.

RESULTS

Cognitive insight, but not clinical insight, was positively associated with ISRP after implicit positive cues. Both clinical and cognitive insight were positively associated with the ability to adjust performance upon receiving explicit feedback, though cognitive insight was more strongly associated with overall task performance.

CONCLUSIONS

Priming with positive cues improved performance on a working memory task in patients with good cognitive insight, but worsened performance in patients with impaired cognitive insight. Furthermore, our findings suggest that the ability to adequately use feedback may be a specific capacity that is related to insight.

Anosognosia as motivated unawareness: the 'defence' hypothesis revisited

Anosognosia for hemiplegia has seen a century of almost continuous research, yet a definitive understanding of its mechanism remains elusive. Essentially, anosognosic patients hold quasi-delusional beliefs about their paralysed limbs, in spite of all the contrary evidence, repeated questioning, and logical argument. We review a range of findings suggesting that emotion and motivation play an important role in anosognosia. We conclude that anosognosia involves (amongst other things) a process of psychological defence. This conclusion stems from a wide variety of clinical and experimental investigations, including data on implicit awareness of deficit, fluctuations in awareness over time, and dramatic effects upon awareness of psychological interventions such as psychotherapy, reframing of the emotional consequences of the paralysis, and first versus third person perspectival manipulations. In addition, we review and refute the (eight) arguments historically raised against the 'defence' hypothesis, including the claim that a defence-based account cannot explain the lateralised nature of the disorder. We argue that damage to a well-established right-lateralised emotion regulation system, with links to psychological processes that appear to underpin allocentric spatial cognition, plays a key role in anosognosia (at least in some patients). We conclude with a discussion of implications for clinical practice.

The Italian validation of the Anosognosia Questionnaire for Dementia in Alzheimer's disease

Although the Anosognosia Questionnaire-Dementia (AQ-D) is one of the main instruments for assessing awareness in Alzheimer's disease (AD), the normative data were until now limited to people from Argentina and Japan. This study aims to validate this instrument in an European context, in particular in an Italian sample. In a multicenter project (Verona, Padova, and Trapani), 130 patients with AD and their caregivers participated in the study. Psychometric characteristics of AQ-D are confirmed indicating that the scale permits the early identification of anosognosia and the correct care management of patients. Indeed, anosognosia results to be present also in patients with very mild AD (moderate: 44.44%; mild: 47.17%; and very mild: 23.73%). Moreover, the results indicate that deficits in awareness may vary in severity and that different types of anosognosia may be identified.

Anosognosia in people with cognitive impairment: association with cognitive deficits and behavioral disturbances

AIMS

To investigate, in a group of subjects at an early stage of cognitive impairment, the relationship between anosognosia and both cognitive and behavioral symptoms by exploring the various domains of insight.

METHODS

One hundred and eight subjects affected by cognitive impairment were consecutively enrolled. The level of awareness was evaluated by means of the Clinical Insight Rating Scale (CIRS). Psychiatric symptoms were evaluated using the Italian version of the Neuropsychiatric Inventory (NPI), whereas memory (memory index, MI) and executive (executive index, EI) functions were explored using a battery of neuropsychological tests and qualified by means of a single composite cognitive index score for each function.

RESULTS

A significant positive correlation between the total NPI score and global anosognosia score was found. Furthermore, both the MI and EI scores were lower in subjects with anosognosia than in those without anosognosia (p < 0.001 and p < 0.007, respectively). When the single domains of the CIRS were considered, anosognosia of reason of visit correlated with the EI score (r = -0.327, p = 0.01) and night-time behavioral disturbances (r = 0.225; p = 0.021); anosognosia of cognitive deficit correlated with depression (r = -0.193; p = 0.049) and the MI score (r = -0.201; p = 0.040); anosognosia of functional deficit correlated with the MI score (r = -0.257; p = 0.008), delusions (r = 0.232; p = 0.015) and aberrant motor behavior (r = 0.289; p = 0.003); anosognosia of disease progression correlated with the MI score (r = -0.236; p = 0.015), agitation (r = 0.247; p = 0.011), aberrant motor behavior (r = 0.351; p = 0.001) and night-time behavioral disturbances (r = 0.216; p = 0.027).

CONCLUSIONS

Our study suggests that, in the early stage of cognitive impairment, anosognosia is associated with both cognitive deficits and behavioral disorders according to the specific functional anatomy of the symptoms.

Different levels of implicit emotional recognition in posterior cortical atrophy (PCA)

Previous single-case reports in posterior cortical atrophy (PCA) have shown preserved nonconscious visual recognition despite the absence of explicit recognition. In this study, we investigated three levels of visual recognition in both a female patient with PCA and a control group during the presentation of neutral, positive, and negative affective stimuli. Our results confirmed the profile of impaired explicit recognition and intact psychophysiological responses in the patient. In addition, she was able to implicitly recognize the valence and intensity of arousal of these stimuli. We suggest that implicit emotional awareness may mediates explicit and psychophysiological recognition in PCA.